HEALTH AND SAFETY

POLICY
Reviewed: July
2020
Policy Applies to:
The Board of Directors, all staff employed by Mercy, credentialed specialists, allied health
professionals, contractors, students, volunteers and visitors.

Related Standards:
 Health and Safety at Work Act, 2015
 Health and Safety at Work Ac(General Risk and Workplace Management)
Regulations 2016
 Health and Safety at Work (Hazardous Substances) Regulations 2017
 EQuIP Standard 3.2 Safety management systems ensure the safety and wellbeing of
consumers / patients, staff, visitors and contractors
 EQuIP Standard 1.5.2 –The infection control system supports safe practice and
ensures a safe environment for consumers / patients and healthcare workers.
 AS/NZS ISO 31000: 2018 Risk Management – Principles and Guidelines
 Australia/New Zealand Standards for Occupational Health and Safety Management
Systems (AS/NZS 4804:2001)
 New Zealand Public Health and Disability Act, 2000

Rationale:
Mercy Hospital Dunedin is committed to ensuring a safe and healthy working environment
and culture for all our employees, specialists, patients, contractors and visitors in our
workplace/ campus.

Objectives:
 To have systems in place that identify, assess, eliminate (where possible) manage and
monitor risks
 To provide a safe environment that complies with, as a minimum, all legislative
requirements
 To promote and provide orientation and training to enable employees to function
safely and effectively in their roles
 To provide forums that enable employees to participate in health and safety risk
management and quality improvement
 To promote health and safety goals and objectives in strategic and service planning
 To consult, cooperate and coordinate with other ‘Persons Conducting a Business or
Undertaking (PCBU)’ who we work with as part of our operation.
Implementation:
As part of its Health and Safety Management System (HSMS), Mercy Hospital undertakes a
number of strategies:

The Board will:

 Retain ultimate responsibility for risk management, statutory compliance and for
determining the appropriate level of health and safety risk acceptable to Mercy
 Understand the activities of Mercy and the hazards and risks associated with its
operation
 Actively engage in health and safety through workplace visits and receiving and
reviewing service area reports
 Direct overall strategy for health and safety and sign off on the tactical plan
 Inform and sign off the Mercy annual Health and Safety Strategy and Plan
 Review the performance of organisational risk management systems through monthly
reporting processes
 Ensure active representation on the Quality and Risk Advisory Committee

The Quality and Risk Advisory Committee will:

 Oversee the practice of risk management, ethical considerations, statutory compliance
strategy and implementation at Mercy
 Review the active Risk Register monthly to feedback any concerns to the organisation
via the committee Chair.
 Ensure that the integrated organisation wide risk management policy and system
identifies and manages identified risks
 Provide an ongoing risk management approach to the review of identified hazards,
incidents and complaints

CEO and Executive will:

 Ensure compliance / leadership in health and safety and the implementation of risk
management, ethics committee and statutory compliance at Mercy
 Develop the organisational tactical plan which integrates health and safety best
practice into all areas of management
 Review the active Risk Register monthly or more frequently as required and ensure
controls are appropriate and monitored for effectiveness.
 Ensure health and safety agenda and discussion is included in Executive, Heads of
Department, Quality and Risk Advisory and Board of Directors meetings
Executive Members have delegated authority for management of risk on behalf of
the CEO.
 Ensure health and safety performance of Managers is completed as part of
performance reviews
 Ensure that Severity Assessment Code (SAC) 1 and 2 events are reported to the Board
and relevant health and safety regulatory body in a timely manner
 Ensure that notifiable event incidents are reported to WorkSafe in a timely manner
Director of Clinical Services will:
 Provide oversight of the role and activities of the Health and Safety Coordinator

Safety Officer
 The Health and Safety Coordinator in partnership with a designated Executive
member, will maintain responsibility as Safety Officer for Fire and Emergency and
provides leadership in policy and staff training and education.

Quality Coordinator
 Manages the process of documenting and monitoring the identified enterprise risks
 Maintains the Mercy Hospital organisational Risk Register
 Meets with Executive on a monthly basis to review active risks. The organisational
risk register is then updated to reflect amended controls and risk status.

Managers, Coordinators and Leaders

 Assist the CEO in discharging responsibility for the implementation of the
Risk Management Framework in their respective departments
 Escalate risks which are outside their control or which require management by the
Executive or CEO
 Ensure all staff within the department are aware of the Health and Safety and Risk
Management Policies and their responsibilities regarding risk
 Ensure the staff in their respective departments have the skills, experience and training
for their roles
 Identify, assess , manage and monitor significant risks to the health and safety of
employees, contractors, credentialed specialists, patients, students, visitors and
volunteers within their service area or department
 Support the election of, and ongoing work undertaken by Health and Safety
Representatives
 So far as is reasonably practicable, keep workers and others affected by their work
healthy and safe. Integrate best practice health and safety into day-to-day management
practices and ensure health and safety information is available to staff
 Ensure orientation, training, and supervision of employees in safe working practices
is provided
 Observe and enforce relevant policies, procedures, legislation and regulations
 Support ongoing and effective injury prevention initiatives
 Investigate incidents and instigate corrective actions and feedback to staff
 Consult with employees regarding health and safety issues during development and
review of procedures and work environment changes
 Have procedures in place for management of emergencies that may arise while
employees are at work
 Review and implement environmental audit recommendations
 HEALTH AND SAFETY
POLICY
Reviewed: July
2020
Human Resources Manager
 Coordinates the Mercy Staff Support Programme

Health and Safety Representatives

Facilitate employee participation in health and safety risk management through:
 Liaising with their Manager, Clinical Coordinator or Team/Shift Leader regarding
health and safety issues for example supporting Infection Prevention and Control
activity.
 Seeking staff opinions on health and safety issues, representing employees and reporting
back to staff regarding health and safety issues via staff meetings and noticeboards
 Notifying risks or hazards to their Manager, Clinical Coordinator or Team Leader
 Attending monthly representative health and safety meetings and disseminating
information to their area of responsibility following these meetings.
 In conjunction with their manager and Health and Safety Coordinator, review and update
the workplace risk (hazard) l register
 Assist in relevant H&S auditing required in their work area, for example category and
risk specific audits
 Assist in orientation and training of new employees to their work area in respect of
hazards and controls specific to their work
 Consulted in the development of relevant policies and procedures for their work area
 Attend ongoing training as provided for their roles.

All Mercy Employees

Are responsible for maintaining their own safety and the safety of others at work and must:
 Follow work practices, procedures, instructions, and rules relating to health and safety to
ensure their health and safety and that of others in the workplace
 Follow Mercy policies that support their health and safety
 Report incidents where policy/process has not been followed so that remedial training
can appropriately be provided
 Maintain a knowledge of hazards they could be exposed to and the controls in place to
minimise risks associated with these hazards
 Advise a Health and Safety representative or Manager of any hazards identified and
of ways to improve health and safety
 Report all incidents and near misses to their Manager according to the Incident Policy
 Commence a job only after appropriate training and consultation with a supervisor or
trained operator as to the proper procedures to follow
 Use protective clothing and safety equipment correctly and whenever required.
 HEALTH AND SAFETY
POLICY
Reviewed: July
2020
 Review staff health and safety performance as a part of the PDR review
 Facilitate the election of Health and Safety representatives and provide ongoing support
and training for the role

Health & Safety Coordinator

 Develop an annual organisational Health and Safety Plan in consultation with
key stakeholders
 Support the CEO, Executive and Heads of Departments in discharging responsibility
for the implementation of the health and safety plan within their respective
departments
 Utilise available tools and opportunities to measure and benchmark health and safety
performance. Monitor trends and provide recommendations to drive organisational HS
Plan and safer systems
 Provides health and safety training and advice to Managers, Clinical Coordinators,
Team Leaders and staff
 Provide leadership and education to the Health and Safety Representatives
 Respond to information and advice requests from Managers, Clinical Coordinators,
Team Leaders and staff
 Notify Managers, Clinical Coordinators, Team Leaders and staff of any identified
health and safety issues, legislative changes or compliance issues relevant to their
service.
 Provide new staff members, students, Credentialed Specialists, Allied Health
professionals, with information, training and protection from hazards based on best
practice standards
 Develop ongoing and effective injury prevention initiatives
 Provide staff screening and ongoing health monitoring associated with specific
workplace hazards with IPC nurse.
 Coordinate and carry out Health and Safety audits
 Ensure the hazard/risk register and hazardous substance inventory are current
 Record, review and report on staff workplace accidents and provides monthly reports and
trend analysis to the Quality and Risk Advisory Committee, Board of Directors,
Managers, Clinical Coordinators, Team Leaders, Health and Safety and Infection Control
Representatives Committee
 In conjunction with the Human Resources Manager, Managers and Team Leaders
provide structured rehabilitation programmes for staff who have had injury or illness
 Develop and implement staff wellness activities
 Maintain a library of relevant information and codes of practice
 Review polices relating to health and safety to ensure they are effective, align with best
practice and appropriately reflect practices at Mercy
 Liaise with the WorkSafe New Zealand with regard to compliance issues
 Coordinate input from external health and safety experts and consultants as required.
 HEALTH AND SAFETY
POLICY
Reviewed: July
2020
Contractors and businesses with overlapping duties of care
Contractors appointed by Mercy and businesses with overlapping duties are responsible for:
 Communicating, consulting, cooperating and coordinating activities to meet their health
and safety responsibilities to workers and others
 Complying with all the Mercy health and safety policies and processes , provided as
part of contract engagement
 The preparation, implementation and maintenance of occupational health and safety
management plans for work directly under their control. This must include risk
assessment, hazard identification and hazard control
 Ensure that the selection, induction and monitoring procedures for all sub- contractors
have been carried out.

Credentialed Specialists and Allied Health Staff

Through Mercy credentialing process, Credentialed Specialists and Allied Health Staff are
made aware that they are responsible for:
 Complying with Mercy health and safety policies, plans and processes, provided as part
of engagement
 Taking responsibility for managing the health and safety risks to staff and of equipment
they bring into the workplace (as Person’s Controlling a Business Unit (PCBU) in their
own right)
 Ensuring Mercy is notified prior to any proposed changes in relevant work processes.
Equipment purchase will be managed in partnership with Mercy, assessing and managing the
associated risks via specialist’s forums, Credentialing process and Product Evaluation
Committee process.
Students
Students accepted for placement at Mercy are made aware by the service area Preceptor that
they are responsible for:
 Complying with the Mercy health and safety policies and processes provided as part
of contract engagement.

Visitors
Staff will support visitors to Mercy to comply with health and safety policies and will inform
them of any specific requirements for the area they are visiting.

Evaluation:
 Risk Register and review process
 Board of Directors Board report
 Mercy Tactical Plan review of objectives
 Health and Safety Plan
 Health and Safety Risk Category Audit
 Quality and Risk Advisory Committee reports
 Infection Prevention and Control Committee reports
  Product Evaluation Committee Reports
 Contractor health and safety questionnaire
 Contractor induction records
 Incident report data analysis
 Patient feedback
 Complaints
 Staff feedback
 Performance Appraisals
 Mercy Certification report, Ministry of Health
 Mercy Equip Accreditation report,

DAA Associated Documents

External
 New Zealand Health and Disability Services- National Reportable Events Policy, 2012
 Institute of Directors, Managing Health and Safety Risks, March 2014
 Business Leaders Health and Safety Forum, Monitoring What Matters, May, 2019.

Internal
 Risk Management Framework
 Health Safety Risk Register, SharePoint (Health and Safety)
 Business Leaders Health and Safety Forum Pledge
 Hazardous Substances Inventory, SharePoint, (Health and Safety)
 Organisational Risk Register
 Emergency Management Policy
 Hazard Management Policy
 Product Evaluation Policy
 Visitors Policy
 Orientation Manual
 Mercy Hospital By-Laws for Credentialed Specialists
 Terms of Reference Quality and Risk Advisory Committee
 Terms of Reference Health and Safety Representatives Committee
 Mercy Hospital Health and Safety Annual Plan
 Contracts Management Policy
 Contractor Health and Safety Questionnaire
 Information Handbook for Contractors
 Absence Management Policy.